Check ( ) One Only

OIG-RCC-4 COMMONWEALTH OF KENTUCKY (Rev.03/08) CABINET FOR HEALTH AND FAMILY SERVICES 922KAR2:100 OFFICE OF THE INSPECTOR GENERAL CHECK ONE ONLY DIVISION OF REGULATED CHILD CARE Initial Application Renewal Request Change/Update APPLICATION FOR CERTIFIED FAMILY CHILD CARE HOME Changes ONLY enter: ______Name on current certificate: 1. PROVIDER IDENTIFICATION Agency Use Only: $10 Check:_____ Name: ______$10 Money Order: ____ First Middle Maiden Last

Date of Birth ______Marital Status (circle one) single married divorced Social Security # ______-- ______-- ______FEIN #______(If applicable)

Address: ______Street (required for listing on certificate) P O Box (if applicable)

______County City Zip Code

(_____)______(______)______Work Number (if applicable) Home Number Name under which telephone is listed

E-mail Address ______

2. DIRECTIONS TO YOUR HOME FROM THE NEAREST MAJOR HIGHWAY

3. HAVE YOU PREVIOUSLY OPERATED A FACILITY THAT WAS LICENSED OR CERTIFIED BY THE CABINET? YES NO If yes, specify the name and address of the facility, and the name of the owner or operator.

4. FOOD SPONSOR: Name of Child Care Food Program Sponsor: ______

5. LOCATION: BUILDING TYPE: House Apartment, Duplex, or Condo Modular or Mobile Home

DO YOU Own or Rent? If renting, you need your landlord’s permission to operate a child care home.

6. HOURS OF OPERATION Do you keep children overnight? No Yes Hours you are open: From ______to ______

Check days you operate child care home: Sun Mon Tues Wed Thurs Fri Sat

7. CHILDREN: List your own children, grandchildren, nieces, nephews, and children in legal custody, step-children, and siblings under age thirteen (13) in your home during the operating hours of your child care home. Child’s Name Date of Birth Social Security # Relationship Dates & Hours Attending

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of 3 8. ADULTS: List the names of adults eighteen (18) years of age or older living in your home. (Use an additional sheet of paper to list more adults in the home)

First Name Middle Name Last Name Relationship Date of Birth Social Security #

9. Substitute/Assistant: List the names of the adult substitutes or assistants that may be providing care for the children in your absence at the home. (Use an additional sheet of paper to list more adults in the home)

First Name Middle Name Last Name Relationship Date of Birth Social Security #

10. Do you have animals in your home? Yes  No  If yes, please list the types of animals? ______

11. STATEMENT OF PROVIDER I certify that this is a true and accurate description of my child care operation on this date and that I have not knowingly misrepresented or offered false information on the application or other required forms. I hereby give the Office of the Inspector General the right to contact social agencies and references listed to verify my statements. I understand the Office of the Inspector General staff shall have the authority to inspect my home and the records required by 922 KAR 2:100 and that those inspections shall be unannounced.

I understand the Office of the Inspector General, Division of Regulated Child Care shall complete a check of the Central Registry pursuant to 922 KAR 1:470 to determine if any adult in my household has had a substantiation of child abuse, neglect, or exploitation by the Cabinet. I understand that my application for certification shall be denied if any adult in my household has been found by the Cabinet or court to have abused or neglected a child. The Division shall also review the criminal record checks of all adults in my household. I understand that my application for certification shall be denied if any adult in my household has been convicted of a violent crime or sex crime as defined in KRS 17.165. I understand that my application for certification shall be denied if there is a history of behavior that may impact the safety or security of a child in care including but not limited to a conviction of a drug related felony (922 KAR 2:100).

I understand that I am required to immediately notify the Office of the Inspector General of any action or change

of 3 Required Documentation to be submitted for Action Requested The application must be submitted with all required documents to be processed. OIG-RCC-4 COMMONWEALTH OF KENTUCKY Initial Application Renewal Request How to Report Changes (Rev.03/08) CABINET FOR HEALTH AND FAMILY SERVICES Application (OIG-RCC-4) (applying to renew existing Name Change 922KAR2:100 $10 non-refundable certificate for additional 2 years) Application (complete Sections 1 & 9) certification fee (check or Application (OIG-RCC-4) money order payable to $10 non-refundable Location/Address Change Kentucky State Treasurer), certification fee (check or Application (complete Sections 1, 2 & 9) Self-Check list (OIG-RCC-6), money order payable to Written local zoning approval Physician’s statement, Kentucky State Treasurer) Results of tuberculosis test on $10 non-refundable Central Add an Adult to the Home/ add substitute or assistant all adults in the home Registry Check fee (payable to Application (complete Sections 1, 8 & 9) (administered within 12months Kentucky State Treasurer), for each Results of tuberculosis test of the date of application), check for adults in the home Criminal records check Criminal records check on all (including substitutes or assistants) Central registry check (OIG-RCC-5) adults in the home (including (OIG-RCC-5), substitutes or assistants), $10 non-refundable Central Central registry check on all Registry Check fee (payable to adults in the home (including Kentucky State Treasurer), for each Changes, other than those listed above, must be reported substitutes or assistants) check for adults in the home, by telephone or letter. (OIG-RCC-5), including substitutes or assistants $10 non-refundable Central Registry Check fee (payable to Kentucky State Treasurer), for each check for adults in the home (including substitutes or assistants),and Written local zoning approval that significantly impacts the operation of my family child care home. Examples of such changes include a move to a new location, marriage and a name change, telephone number changes, new adults in the home, ceasing operation, or becoming a licensed provider. I understand that this application applies only to the location listed on this form and that if I move; I must immediately apply for a certificate at my new location.

I have read and understand the family child care certification requirements as specified in 922 KAR 2:100.

______

Provider’s Signature Date

A certified check or money order made payable to the “Kentucky State Treasurer” in the amount of ten dollars ($10.00 non-refundable) must accompany your completed application. The application will NOT be processed without payment.

Mail the certified check or money order to:

Office of the Inspector General Division of Regulated Child Care 275 E. Main Street, 5 E-F Frankfort, KY 40621-0001